Pcap Guidelines 3d1c4t

PCAP GUIDELINES

Etiology • Outpatient and in-patients: bacterial > viral • For bacterial: Streptoccocus pneumoniae> H. influenzae> Mycoplasma sp.> Chlamydia sp.

Risk Classification PCAP A Minimal

PCAP B Low

PCAP C Moderate

PCAP D High

Co-morbids

None

+

+

+

Compliant Caregiver

+

+

None

None

Ability to Follow up

+

+

None

None

None

Mild

Moderate

Severe

Yes

Yes

No

No

> 11 months

> 11 months

< 11 months

< 11 months

> Or = 50

> 50

> 60

> 70

1-5 yrs

> Or = 40

> 40

> 50

> 50

> 5 yrs

> Or = 30

> 30

> 35

> 35

Variables

Dehydration Feeding Age RR 2-12 mos

PCAP C Moderate

PCAP D High

Intercostal/ subcostal

Supraclavicular

Head bobbing

+

+

Cyanosis

+

+

Variables

PCAP A Minimal

PCAP B Low

Retractions

Grunting

+

Apnea

+

Sensorium

Awake

Awake

Complications Action

OPD

OPD

Follow up at end of treatment

Follow up after 3 days

Irritable

Lethargic/ stuporous/ comatose

+

+

it to wards

it to ICU Refer to specialist

Diagnostics • No diagnostic aids initially requested for PCAP A or B managed on an outpatient basis • Routine exams for PCAP C or D: – CXR PAL – WBC count – CS: blood (for PCAP D), pleural fluid, ETA upon intubation – Blood gas/O2 sat

Diagnostics • Sputum CS for older children • ESR and CRP are not routinely requested

Predictors of bacterial pathogen • Clinical prediction using a bacterial pneumonia score – BPS ≥ 4 ~ (+) bacterial pathogen in hospitalized patients 1 month – 5 years

• Probable organisms acc. to age – Increase age, higher chance of bacterial pathogen, increasing frequency of atypical organism

• Decreased breath sounds

Treatment • Antibiotics are recommended in: 1. Patients classified as either PCAP A or B and is: (a) beyond 2 years of age; or (b) having high grade fever without wheeze 2. Patients classified as PCAP C and is: (a) beyond 2 years of age; (b)having high grade fever without wheeze; (c) having alveolar consolidation in chest x-ray; (d) or having WBC count > 15,000 3. Patients classified as PCAP D

Treatment • Empiric treatment (bacterial etiology): – PCAP A or B w/o previous antibiotic: Amoxicillin 45 mg/kg/day in 3 divided doses x 3 days (min) • Macrolide if w/ hypersensitivity of amoxicillin • Other regimens: Co-trimoxazole, azithromycin, erythromycin, co-amoxiclav, clarithromycin

– PCAP C w/o previous antibiotic and has complete immunization against Hib: Penicillin G 100,000 ‘u’/kg/day • Oral amoxicillin in patients who can tolerate feeding (comparable to parenteral penicillin)

Treatment • Empiric treatment (bacterial etiology): – PCAP C w/o Hib immunization: IV ampicillin 100 mg/kg/day in 4 divided doses • Monotherapy (parenteral ampicillin) or combination therapy (IV penicillin + chloramphenicol) in patients who cannot tolerate feeding • Other regimens: Amoxicillin/sulbactam, cefuroxime, chloramphenicol

– PCAP D: consult a specialist

Treatment • If CA-MRSA suspected, refer immediately to the appropriate specalist. • Strategies in clinical management of MRSA: – Follow antibiotic susceptibility based on culture studies – Vancomycin remains to be the 1st line therapy for severe infections possibly caused by MRSA – CA-MRSA were more likely to be synergistically inhibited by vancomycin + gentamicin vs. vancomycin alone

Treatment • Initial treatment (viral etiology): – Ancillary treatment – Oseltamivir 2 mg/kg/dose BID x 5 days may be given for laboratory confirmed influenza

Response to antibiotics • Decrease in respiratory signs (i.e. tachypnea) and defervescense within 72 hours after initiation of antibiotic – FAVORABLE – Nonsevere: RR>5 bpm slower than baseline – Severe: defervescense, decrease in tacypnea & chest indrawing, increase in O2 sat & ability to feed within 48 hours

• Persistence of symptoms beyond 72 hours after initiation of antibiotics – RE-EVALUATE

Response to antibiotics • Improved: RR < age-specific range without chest indrawing or any danger signs (central cyanosis, inability to drink, abnormally sleepy or convulsions) • Treatment failure – Same: RR > age-specific range WITHOUT chest indrawing or any danger signs – Worse: Developed chest indrawing or any of the danger signs

Response to antibiotics • If a patient w/ PCAP A or B is not responding to antibiotics w/in 72 hours, consider: – Change the initial antibiotic; or – Start an oral macrolide; or – Re-evaluate diagnosis

• Causes of treatment failure: co-infection w/ RSV, non-adherence to treatment

Response to antibiotics • If a patient w/ PCAP C is not responding to antibiotics w/in 72 hours, consider: – Penicillin resistant Strep pneumoniae; or – Presence of pulmonary or extrapulmonary complications; or – Other diagnosis

• Causes of treatment failure: antibiotic resistance, clinical sepsis, progressive pneumonia, mixed infection

Response to antibiotics • If a patient w/ PCAP D is not responding to antibiotics w/in 72 hours, consider: – Immediate re-consultation w/ a specialist

Response to antibiotics • Switch from IV to oral 2-3 days after initiation of antibiotics recommended if: – Responding to the initial antibiotic therapy – Able to feed w/ intact GI absorption – Without pulmonary or extrapulmonary complications

• Switch from 3 days of IV ampicillin to 4 days of amoxicillin (preferred) or cotrimoxazole

Ancillary treatment • Oxygen and hydration if needed among inpatients • Cough preparations, chest physiotherapy, pNSS nebulization, steam inhalation, topical solution, bronchodilators are not routinely used • A bronchodilator may be used if with wheezing

Prevention • Pneumococcal and Hib vaccination • Zinc supplementation may be istered to prevent pneumonia • Handwashing using antibacterial soaps • Breastfeeding